RESUMEN
OBJECTIVES: To evaluate management changes and outcomes in critically ill children after formal echocardiography. DESIGN: Retrospective cohort study between January 1, 2011, and December 31, 2020. SETTING: Tertiary care children's hospital. PATIENTS: Patients from 1 to 18 years who had formal echocardiography within 72 hours of ICU admission and who were intubated and on vasoactive infusions at the time of the study. Patients were stratified into two cardiac function groups: 1) near-normal cardiac function and 2) depressed cardiac function. METHODS: Clinical variables were abstracted from the electronic medical record and placed in time sequence relative to echocardiography. Vasoactive and fluid management strategies in place before echocardiography were associated with markers of tissue perfusion and volume overload. Management changes after echocardiography were characterized and associated with outcomes. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among patients eventually found to have depressed cardiac function, the use of vasoconstrictors was associated with worse lactate clearance and oxygen extraction ratio. Use of vasoconstrictors in this cohort was also associated with a more liberal fluid management strategy, evidence of increased lung water, and a worse Sp o2 /F io2 . An echocardiogram demonstrated depressed cardiac function was likely to be followed by management changes that favored inotropes and more conservative fluid administration. Patients with depressed cardiac function who were switched to inotropes were more likely to be extubated and to wean off vasoactive support compared with those patients who remained on vasoconstrictors. CONCLUSIONS: Among patients with depressed cardiac function, alterations in management strategy after echocardiography are associated with shortened duration of intensive care interventions.
Asunto(s)
Enfermedad Crítica , Ecocardiografía , Humanos , Estudios Retrospectivos , Niño , Enfermedad Crítica/terapia , Ecocardiografía/métodos , Masculino , Femenino , Lactante , Adolescente , Preescolar , Fluidoterapia/métodos , Unidades de Cuidado Intensivo Pediátrico , Vasoconstrictores/uso terapéutico , Vasoconstrictores/administración & dosificaciónRESUMEN
BACKGROUND: Histamine-releasing factor (HRF) is implicated in allergic diseases. We previously showed its pathogenic role in murine models of asthma. OBJECTIVE: We aim to present data analysis from 3 separate human samples (sera samples from asthmatic patients, nasal washings from rhinovirus [RV]-infected individuals, and sera samples from patients with RV-induced asthma exacerbation) and 1 mouse sample to investigate correlates of HRF function in asthma and virus-induced asthma exacerbations. METHODS: Total IgE and HRF-reactive IgE/IgG as well as HRF in sera from patients with mild/moderate asthma or severe asthma (SA) and healthy controls (HCs) were quantified by ELISA. HRF secretion in culture media from RV-infected adenovirus-12 SV40 hybrid virus transformed human bronchial epithelial cells and in nasal washings from experimentally RV-infected subjects was analyzed by Western blotting. HRF-reactive IgE/IgG levels in longitudinal serum samples from patients with asthma exacerbations were also quantified. RESULTS: HRF-reactive IgE and total IgE levels were higher in patients with SA than in HCs, whereas HRF-reactive IgG (and IgG1) level was lower in asthmatic patients versus HCs. In comparison with HRF-reactive IgElow asthmatic patients, HRF-reactive IgEhigh asthmatic patients had a tendency to release more tryptase and prostaglandin D2 on anti-IgE stimulation of bronchoalveolar lavage cells. RV infection induced HRF secretion from adenovirus-12 SV40 hybrid virus transformed bronchial epithelial cells, and intranasal RV infection of human subjects induced increased HRF secretion in nasal washes. Asthmatic patients had higher levels of HRF-reactive IgE at the time of asthma exacerbations associated with RV infection, compared with those after the resolution. This phenomenon was not seen in asthma exacerbations without viral infections. CONCLUSIONS: HRF-reactive IgE is higher in patients with SA. RV infection induces HRF secretion from respiratory epithelial cells both in vitro and in vivo. These results suggest the role of HRF in asthma severity and RV-induced asthma exacerbation.
Asunto(s)
Asma , Infecciones por Enterovirus , Infecciones por Picornaviridae , Humanos , Animales , Ratones , Histamina , Rhinovirus , Inmunoglobulina E , Inmunoglobulina G , Infecciones por Picornaviridae/complicacionesRESUMEN
OBJECTIVES: Evaluate the reliability of ultrasound to measure quadriceps femoris muscle thickness in critically ill children and to describe serial changes in quadriceps femoris muscle thickness in relation to fluid balance and nutritional intake. DESIGN: Prospective observational study. SETTING: Tertiary care children's hospital. PATIENTS: Inpatients age 3 months to 18 years recently admitted to the ICU who were sedated and mechanically ventilated at the time of the first ultrasound scan. METHODS: Prospective observational study to examine the reliability of averaged ultrasound measurements of quadriceps femoris muscle thickness. Change in average quadriceps femoris muscle thickness over time was correlated with fluid balance and nutritional intake. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Averaged quadriceps femoris muscle thickness demonstrated good to excellent reliability when comparing pediatric critical care providers to pediatric radiologists and when comparing between different pediatric critical care providers. We found no significant association between fluid balance over 1 or 3 days and change in quadriceps femoris muscle thickness over the same time frame. However, there was a significant association between percent of goal calories (p < 0.001) or percent of goal protein (p < 0.001) over 6 days and change in quadriceps femoris muscle thickness over the same time frame. CONCLUSIONS: Averaged ultrasound measurements of quadriceps femoris muscle thickness demonstrate good to excellent reliability, are not confounded by fluid balance, and are useful for tracking changes in muscle thickness that are associated with nutritional intake. Ultrasound-based assessment of quadriceps femoris is a clinically useful tool for evaluating muscle mass and may be a proxy for nutritional status.
Asunto(s)
Enfermedad Crítica , Músculo Cuádriceps , Niño , Cuidados Críticos , Humanos , Músculo Cuádriceps/diagnóstico por imagen , Reproducibilidad de los Resultados , UltrasonografíaRESUMEN
Healthcare regulatory bodies have escalated concerns regarding the use of point-of-care ultrasound by nonradiology and noncardiology physicians. A recently published PCCMPerspective identified that data do not support many of these concerns and addressed common misconceptions associated with point-of-care ultrasound use in the critical care setting. Indeed, the global point-of-care ultrasound community and specifically the pediatric critical care community have the opportunity to be leaders in demonstrating how to translate new skills and technologies to the bedside in a safe and effective manner. We seek to extend the conversation and propose next steps in supporting integration of point-of-care ultrasound in pediatric critical care practice.
Asunto(s)
Médicos , Sistemas de Atención de Punto , Niño , Cuidados Críticos , Atención a la Salud , Humanos , UltrasonografíaRESUMEN
Focused cardiac ultrasonography (FoCUS) has become an important diagnostic tool for acute care physicians. FoCUS allows real-time visualization of the heart and, in combination with the physical examination, acts as a hemodynamic monitor to manage patient care in acute situations. Most of the available perioperative literature has focused on adult patients. Little has been published on the perioperative application of FoCUS for pediatric patients. This article provides an overview of FoCUS used at the bedside by pediatric anesthesiologists. Variations in clinical applications, technical aspects, and interpretation of FoCUS findings in children are described. Discussion of training and competency is included. Barriers to implementation by pediatric intensivists and emergency medicine physicians include a lack of understanding of indications and training opportunities in pediatric FoCUS. It is likely that similar barriers exist in pediatric anesthesiology resulting in underutilization of FoCUS. The use of FoCUS in the pediatric operating room, however, may positively impact care of infants and children and should be encouraged.
Asunto(s)
Enfermedades Cardiovasculares/diagnóstico por imagen , Ecocardiografía , Evaluación Enfocada con Ecografía para Trauma , Corazón/diagnóstico por imagen , Pediatría/métodos , Atención Perioperativa/métodos , Adolescente , Factores de Edad , Enfermedades Cardiovasculares/fisiopatología , Enfermedades Cardiovasculares/terapia , Niño , Preescolar , Toma de Decisiones Clínicas , Corazón/fisiopatología , Humanos , Lactante , Valor Predictivo de las Pruebas , Pronóstico , Flujo de TrabajoAsunto(s)
Cuidados Críticos , Niño , Humanos , Desarrollo de Programa , Encuestas y Cuestionarios , UltrasonografíaRESUMEN
OBJECTIVES: To assess current diagnostic bedside ultrasound program core element (training, credentialing, image storage, documentation, and quality assurance) implementation across pediatric critical care medicine divisions in the United States. DESIGN: Cross-sectional questionnaire-based needs assessment survey. SETTING: Pediatric critical care medicine divisions with an Accreditation Council of Graduate Medical Education-accredited fellowship. RESPONDENTS: Divisional leaders in education and/or bedside ultrasound training. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Fifty-five of 67 pediatric critical care medicine divisions (82%) with an Accreditation Council of Graduate Medical Education-accredited fellowship provided responses. Overall, 63% of responding divisions (34/54) were clinically performing diagnostic bedside ultrasound studies with no difference between divisions with large versus small units. Diagnostic bedside ultrasound training is available for pediatric critical care medicine fellows within 67% of divisions (35/52) with no difference in availability between divisions with large versus small units. Other core elements were present in less than 25% of all divisions performing clinical studies, with a statistically significant increase in credentialing and documentation among divisions with large units (p = 0.048 and 0.01, respectively). All core elements were perceived to have not only high impact in program development but also high effort in implementation. Assuming that all structural elements could be effectively implemented within their division, 83% of respondents (43/52) agreed that diagnostic bedside ultrasound should be a core curricular component of fellowship education. CONCLUSIONS: Diagnostic bedside ultrasound is increasingly prevalent in training and clinical use across the pediatric critical care medicine landscape despite frequently absent core programmatic infrastructural elements. These core elements are perceived as important to program development, regardless of division unit size. Shared standardized resources may assist in reducing the effort in core element implementation and allow us to measure important educational and clinical outcomes.
Asunto(s)
Curriculum , Educación de Postgrado en Medicina/estadística & datos numéricos , Pediatría/educación , Sistemas de Atención de Punto/estadística & datos numéricos , Ultrasonografía , Niño , Habilitación Profesional/estadística & datos numéricos , Cuidados Críticos/métodos , Estudios Transversales , Educación de Postgrado en Medicina/métodos , Becas/estadística & datos numéricos , Humanos , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Desarrollo de Programa , Encuestas y CuestionariosAsunto(s)
Asma/diagnóstico , Monitoreo de Gas Sanguíneo Transcutáneo/métodos , Adolescente , Pruebas Respiratorias , Monóxido de Carbono/metabolismo , Niño , Estudios de Cohortes , Convalecencia , Diagnóstico Diferencial , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Pronóstico , Estudios ProspectivosRESUMEN
RATIONALE: The effects of fluid administration during acute asthma exacerbation are likely unique in this patient population: highly negative inspiratory intrapleural pressure resulting from increased airway resistance may interact with excess fluid administration to favor the accumulation of extravascular lung water, leading to worse clinical outcomes. OBJECTIVES: Investigate how fluid balance influences clinical outcomes in children hospitalized for asthma exacerbation. METHODS: We analyzed the association between fluid overload and clinical outcomes in a retrospective cohort of children admitted to an urban children's hospital with acute asthma exacerbation. These findings were validated in two cohorts: a matched retrospective and a prospective observational cohort. Finally, ultrasound imaging was used to identify extravascular lung water and investigate the physiological basis for the inferential findings. MEASUREMENTS AND MAIN RESULTS: In the retrospective cohort, peak fluid overload [(fluid input - output)/weight] is associated with longer hospital length of stay, longer treatment duration, and increased risk of supplemental oxygen use (P values < 0.001). Similar results were obtained in the validation cohorts. There was a strong interaction between fluid balance and intrapleural pressure: the combination of positive fluid balance and highly negative inspiratory intrapleural pressures is associated with signs of increased extravascular lung water (P < 0.001), longer length of stay (P = 0.01), longer treatment duration (P = 0.03), and increased risk of supplemental oxygen use (P = 0.02). CONCLUSIONS: Excess volume administration leading to fluid overload in children with acute asthma exacerbation is associated with increased extravascular lung water and worse clinical outcomes.
Asunto(s)
Asma/fisiopatología , Asma/terapia , Agua Pulmonar Extravascular/fisiología , Fluidoterapia/métodos , Estado de Hidratación del Organismo/fisiología , Adolescente , Boston , Niño , Estudios de Cohortes , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Estudios Prospectivos , Estudios Retrospectivos , Resultado del TratamientoAsunto(s)
Músculo Cuádriceps , Muslo , Biomarcadores , Niño , Enfermedad Crítica , Humanos , Unidades de Cuidado Intensivo Pediátrico , UltrasonografíaRESUMEN
BACKGROUND: Long-gap esophageal atresia (LGEA) may have clinical and syndromic presentations different from those of esophageal atresia (EA) that affects shorter segments of the esophagus (non-LGEA). This may suggest unique underlying developmental mechanisms. OBJECTIVES: We sought to characterize clinical differences between LGEA and non-LGEA by carefully phenotyping a cohort of EA patients, and furthermore to assess molecular genetic findings in a subset of them. METHODS: This is a retrospective cohort study to systematically evaluate clinical and genetic findings in EA infants who presented at our institution over a period of 10 years (2005-2015). RESULTS: Two hundred twenty-nine EA patients were identified, 69 (30%) of whom had LGEA. Tracheoesophageal fistula was present in most non-LGEA patients (158 of 160) but in only 30% of LGEA patients. The VACTERL association was more commonly seen with non-LGEA compared to LGEA (70 vs. 25%; p < 0.001). Further, trisomy 21 was more common in LGEA than in non-LGEA. 25% of LGEA patients had an isolated EA diagnosis without other anomalies, compared to <1% for non-LGEA. Chromosomal microarray analysis showed copy number variations (CNV) in 4 of 39 non-LGEA patients and 0 of 3 LGEA patients. A review of the ClinGen database showed that none of those CNV have been previously described with EA. CONCLUSIONS: LGEA represents a unique type of EA. Compared to non-LGEA, it is more likely to be an isolated defect and associated with trisomy 21. Further, it is less commonly seen with VACTERL anomalies. Our findings suggest the involvement of unique pathways that may be distinct from those causing non-LGEA.
Asunto(s)
Variaciones en el Número de Copia de ADN , Atresia Esofágica/complicaciones , Atresia Esofágica/genética , Canal Anal/anomalías , Boston , Síndrome de Down/epidemiología , Atresia Esofágica/clasificación , Esófago/anomalías , Femenino , Cardiopatías Congénitas/epidemiología , Humanos , Lactante , Recién Nacido , Riñón/anomalías , Deformidades Congénitas de las Extremidades/epidemiología , Masculino , Análisis por Micromatrices , Estudios Retrospectivos , Columna Vertebral/anomalías , Tráquea/anomalías , Fístula Traqueoesofágica/epidemiologíaAsunto(s)
Antiasmáticos/uso terapéutico , Asma/tratamiento farmacológico , Omalizumab/uso terapéutico , Rhinovirus , Enfermedad Aguda , Adolescente , Niño , Estudios de Cohortes , Femenino , Humanos , Masculino , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
OBJECTIVE: Peripheral arterial catheterization is a common invasive procedure performed in critically ill children. However, the benefits of using ultrasound guidance for this procedure in critically ill children, especially when used by inexperienced trainees, are unclear. Our aims were to evaluate whether the use of ultrasound guidance for the placement of radial arterial catheters reduced time and improved success when compared with the palpation method and also to determine patient and trainee variables that influence procedure outcomes. Finally, we evaluated whether adoption of ultrasound guidance among trainees comes at the expense of learning landmark-based methods. DESIGN: Prospective observational cohort. SETTING: University affiliated PICU. PATIENTS: A total of 208 procedures performed by 45 trainees in 192 unique patients (1 mo to 20 yr old) were observed. INTERVENTION: Implementation of ultrasound curriculum. MEASUREMENTS AND MAIN RESULTS: The main outcome measures were time and number of attempts required for the procedure. Compared with palpation method, ultrasound guidance was associated with reduced procedure time (8.1 ± 5.2 min compared with 16.5 ± 8.8 min; p < 0.001), reduced number of attempts (3.1 ± 2.6 attempts compared with 6.9 ± 4.2 attempts; p < 0.001), and improved first attempt success rate (28% compared with 11%; p = 0.001) even after adjusting for key confounders in multivariate random effects models. The factors most likely to interfere with peripheral arterial catheterization are patient age, patient systolic blood pressure, patient body mass index, degree of fluid overload, and trainee months in fellowship. The use of ultrasound guidance mitigates the influence of each of these factors. We found no evidence that the adoption of ultrasound guidance by trainees is associated with reduced proficiency in landmark-based methods. CONCLUSIONS: The use of ultrasound guidance by trainees for radial artery catheterization in critically ill children is associated with improved outcomes compared with the palpation method.
Asunto(s)
Cateterismo Periférico/métodos , Cuidados Críticos/métodos , Educación de Postgrado en Medicina , Pediatría/educación , Ultrasonografía Intervencional , Adolescente , Boston , Niño , Preescolar , Competencia Clínica , Enfermedad Crítica , Femenino , Humanos , Lactante , Masculino , Evaluación de Resultado en la Atención de Salud , Estudios Prospectivos , Método Simple Ciego , Factores de Tiempo , Adulto JovenAsunto(s)
Asma/etiología , Asma/virología , Inmunoglobulina E/sangre , Infecciones por Picornaviridae/complicaciones , Rhinovirus/inmunología , Adolescente , Asma/sangre , Asma/inmunología , Niño , Femenino , Humanos , Masculino , Infecciones por Picornaviridae/sangre , Infecciones por Picornaviridae/inmunología , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVE: To discuss pediatric intensivist-driven ultrasound and the exigent need for research and practice definitions pertaining to its implementation within pediatric critical care, specifically addressing issues in ultrasound-guided vascular access and intensivist-driven echocardiography. CONCLUSIONS: Intensivist-driven ultrasound improves procedure safety and reduces time to diagnosis in clinical ultrasound applications, as demonstrated primarily in adult patients. Translating these applications to the PICU requires thoughtful integration of the technology into practice and would best be informed by dedicated ultrasound research in critically ill children.